Comparison Of Continuous Ambulatory Peritoneal Dialysis And Hemodialysis On End-stage Renal Disease With Decompensated Liver Cirrhosis

Background and ObjectiveEnd-stage renal disease (ESRD) has become one of the major diseases which effects human health in the21st century.In chaina, the morbidity rates of chronic kidney disease(CKD) and ESRD are increasing year by year.At the same time, the morbidity rate of chronic liver disease(CLD) is increasing year by year. So ESRD patients with advanced hepatocirrhosis (HC) are more and more. The treatment for these patients has become a thorny problem in our clinical work. There are three main renal replacement therapy that are used in clinical practice including hemodialysis(HD)、peritoneal dialysis(PD) and kidney transplant. China is the biggest developing country, The level of economic development is backward,and limited source of transplant kidneys,so there are many difficulties for the development and popularization of kidney transplant.So the majority of patients with ESRD accept dialysis treatment. PD has many advantages to compare to HD,for example easy operation, to better protect the residual renal function, less impact on hemodynamics and coagulation function and so no. It has become one of the main modality of renal replacement therapy and more and more accepted by patients with ESRD. Nevertheless, the majority of dialysis patients accepted hemodialysis. ESRD patients with advanced cirrhosis, because the pathophysiological features of advanced cirrhosis, dialysis treatment is different from other dialysis patients, for the choice of dialysis modality, domestic and overseas scholars have the different views.Chinese scholars observed17patients with uremia and schistosomal cirrhosis who were given hemodialysis treatment, the clinical efficacy was marked. They suggested that peritoneal dialysis should not be used as the preferred method of treatment for such patients. Some scholars believe that there are many problems if PD is used for such patients:aggravate malnutrition and hypoalbuminemia, the clinical efficacy is not ideal, inadequate dialysis, retention of water and sodium, peritoneal dialysis ultrafiltration failure is caused by the peritoneal cavity infection.For decompensated cirrhosis patients, portal hypertension,massive ascites, hypoproteinemia and can cause systemic hypovolemia, even occur hypotension, And hemodialysis is accomplished in extracorporeal circulation,it influence hemodynamics, thus, effective circulating blood volume further reduced.At the same time, internal environment’s osmotic pressure rapidly change in short time during hemodialysis,it can cause brain cell edema and increase the risk of hepatic encephalopathy.besides, use of anticoagulants, platelet destruction under extracorporeal circulation, and then the bleeding tendency aggravated, so hemodialysis is limited. In contrast, PD do not need extracorporeal circulation and anticoagulants, by home dialysis their social activities are affected, by peritoneal dialysis catheter ascites can be drained constantly. Paul, DeVecchi et al concidered PD can effectively protect residual renal function, protein loss can be maintained at a low level for a long time, the clinical efficacy is affected by end-stage liver disease. Some foreign scholars thought that since the double peritoneal dialysis catheter system was used, the peritoneal cavity infection rate has decreased to lower than40patient-months,it was similar with that of non cirrhotic patients.It was reported a comparative analysis of30cases of liver cirrhosis patients with PD and60cases of non-cirrhotic patients with PD found the solute clearance rate and ultrafiltration capacity of liver cirrhosis patients were significantly higher than that of non-cirrhotic patients. This shows that PD is suitable for this kind of patients.Which dialysis is more superior? In our study we compared the clinical efficacy of peritoneal dialysis and hemodialysis in patients with ESRD and decompensated liver cirrhosis, in order to define an optimal dialysis modality.MethodsThe analysis included data from30patients with ESRD and decompensated liver cirrhosis who had undergone dialysis for at least6months (between May2004and August2012) at the Department of Nephrology of the First Affiliated Hospital of Zhengzhou University. The patients were divided into an HD group (n=16) and a PD group (n=14). None of the selected cases had severe heart failure, diabetes mellitus or therioma and so on.Continuous ambulatory peritoneal dialysis (CAPD) was undertaken using double cuff peritoneal dialysis tubes and lactate peritoneal dialysis solution (Baxter, America). During this procedure the patients received6to8L of peritoneal dialysis solution over a period of24h. Hemodialysis was undertaken using the dialyzer machines (Fresenius,Germany). The patients received bicarbonate hemodialysis for4or5h, two or three times a week. During the hemodialysis sessions the patients were given antihypertensive, lipid lowering and phosphorus reducing drugs, together with active vitamin D, erythropoietin and iron supplements and so on. The dosages were adjusted according to the patient’s condition.All cases were followed up from the beginning of dialysis untikl death or until31August2012. The surviving patients had received dialysis therapy for over3years. Demographic and clinical data (dialysis duration, blood pressure, laboratory evaluations, urine volume and so on) recorded for6to12months were analyzed for all patients. The incidence of peritonitis and other complications was analyzed together with survival data. Quality of life was recorded using the Kidney Disease Quality of Life Short Form (KDQOL-SF version1.2) questionnaire survey.Statistical analysis was undertaken using SPSS version17.0software. Results are reported as means and standard deviations (Mean±SD). Between group differences were analyzed by independent two-sample t-tests and chi square tests. Values of P <0.05were considered statistically significant.Results5Study populationThe study population included16patients (nine men and seven women) who began HD at a mean age of48.6years (range:34to68years) and who had undergone dialysis for a mean of25.3months (range:7to42months). The PD group comprised14patients (eight men and six women) who began dialysis at a mean age45.6years (range:36to68years) and who had undergone dialysis for a mean of33.0months (range:11to44years). In HD group,3cases died when dialysis for less than1year,5cases died when dialysis for less than2years,3cases died when dialysis for less than3years,5cases undergoing dialysis for more than3years; In PD group,1cases died when dialysis for less than1year,2cases died when dialysis for less than2years,3cases died when dialysis for less than3years,8cases undergoing dialysis for more than3years.There were no significant difference between the two groups with respect to pre-dialysis demographic or clinical parameters.2. Outcome of dialysisAfter6and12months of dialysis, body weight, blood levels of2-microglobulin and total cholesterol were significantly higher in patients undergoing HD than in those undergoing PD (P<0.05). In addition, blood urea nitrogen, serum creatinine, residual urine volume, platelet count and glomerular filtration rate (GFR) were all significantly lower in the HD group than in the PD group (P<0.05).3. Quality of life assessmentsAt both6and12months, quality of life evaluations of’the effects of kidney disease’,’work status’,’quality of social interaction’and’social functioning’were significantly higher in the PD group than in the HD group (P<0.05), At12months scores for ’patient satisfaction’,’physical functioning’,’role physical’and ’symptom/problem items’ were also significantly higher in the PD group than in the HD group (P<0.05).4. ComplicationsThe incidence of repeated hypotension and convulsion at6and12months was significantly higher in the HD group than in the PD group (P<0.05). At12months, the incidences of subcutaneous and archenteric hemorrhage were also significantly higher in the HD group (P<0.05).At12months,three patients in the PD group (23.1%) each developed three episodes of bacterial peritonitis, which was equivalent to one event every52patient-months, The peritonitis were cured by use of antibiotics.5. Patient survival The1-year survival rate in patients continuing the same mode of dialysis for1year was81.3%in the HD group and92.9%in the PD group. The corresponding2-and3-year survival rates were significantly higher in the PD group (85.7%and71.4%, respectively) than in the HD group(50.0%and31.3%;P<0.05).In group HD, the major causes of death were hemorrhage, followed by cardiovascular and cerebrovascular complications; group PD, the major causes of death were peritonitis, followed by hemorrhage and cardiovascular and cerebrovascular complications.ConclusionsTaken together our findings suggest that PD has many advantages over HD for patients with ESRD and co-existing advanced liver cirrhosis. PD provides better the treatment of ascites induced by cirrhosis, better the protection of residual renal function,more complete toxin removal and less impairment of coagulation function than HD. Its use is also associated with a better the quality of life, fewer complications, and increased long-term survival.